Request Patient Film
Date of Birth
Daytime Phone Number
Date(s) of Service
Type of Exam (please check all that apply)
PET/CT – allow 24 hours
If the PET/CT CD will be given to a Radiation Oncologist check here
Dexa / Bone Density
Pick Up CD at
Glendale Office 16222 N 59th Ave C105 Glendale Az 85306
Administrative Office 13943 N 91st Ave Peoria Az 85381
Films (specifically no CD) have been requested by my healthcare provider.
Name of Provider (If “Films” is checked above )
Provider Phone number (If “Films” is checked above )
Send me a copy of my responses.
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